Who Will Care for the Uninsured in a Managed Care World? John Conley Lecture | Health Care Economics, Insurance, Payment | JAMA Otolaryngology–Head & Neck Surgery | JAMA Network
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Original Article
March 2000

Who Will Care for the Uninsured in a Managed Care World?John Conley Lecture

Author Affiliations

From the Church Health Center of Memphis, Memphis, Tenn.

Arch Otolaryngol Head Neck Surg. 2000;126(3):290-292. doi:10.1001/archotol.126.3.290

As a family practitioner, I feel about as out of place speaking to the American Head and Neck Society as I did when I spoke to the worldwide gathering of the presidents of the Elvis Presley fan clubs, yet you have treated me equally as well as they did.

What I do is provide health care to the working poor of Memphis, Tenn, at a place known as the Church Health Center of Memphis. We care for those people who work to make our lives comfortable. They shine our shoes, cook our food, and will one day dig our graves. They are the forgotten people in our society, and when they get sick, they have few options for health care. The safety net that we have relied on to serve them now has many large gaping holes.

At the Church Health Center of Memphis, the medical and faith communities have joined together to provide quality health care at an affordable price. The Church Health Center of Memphis has 25,000 patients and 30,000 patient visits a year. With a paid staff to support 5 physicians, the center uses the volunteer support of more than 400 physicians, 65 dentists, and 30 optometrists to offer on-site care 70 hours a week and subspecialty care on a charitable basis in physicians' offices. Every hospital and laboratory in the city provide diagnostic tests and inpatient care without charge. Begun in 1987, the center supports its $5 million operating budget with sliding-scale fees for patients and financial support from 150 religious congregations and thousands of individuals, businesses, and foundations. We are successful because we ask everyone to do his or her fair share, but no one is asked to do more than he or she is willing to do. Yet the need for what we do is growing in Memphis and across the country. Back during the days of health care reform—if anyone remembers health care reform—it was said that there were 37 million uninsured Americans. That number is now reported to be 43 million, but no one really knows the actual figure. What is happening to what was once a benevolent health care system?

In a health care world now increasingly dominated by managed care, who will care for your housekeeper when he or she gets sick? What happens when the gardener trips and breaks his or her ankle? Who performs the surgery on the dishwasher who has cancer?

Before I address these questions, I want to look historically at the problem of the uninsured. When did it become a problem? There are surgeons in this room who remember how it was before 1965. Before that fateful date, one third of every physician's practice was expected to be charity care. Teaching hospitals were staffed by private physicians who were assigned their day in the charity clinics. This all changed in 1965 with the advent of Medicare and Medicaid. At that point, signs went up that said, "Payment expected at time of service." No more turkeys, no more bartering, yet physicians still reserved the right to mark the fee ticket "no charge." Then, with the dawn of managed care, physicians became providers. And all too often, employees who are pressured to always check the boxes. When asked about our commitment to care for all patients who need our skills, too many of us, along with hospitals, have confused bad debt with true charity care. There are now physicians younger than 40 years who have never treated a patient knowing up front that he or she will not get paid. This would never have been the case 30 years ago.

I know all too well that much more goes into charity care than the physician's time. Who will pay for the magnetic resonance imaging scan? What good is a brilliant diagnosis if the patient cannot afford the medicine? But I would like to offer you 10 reasons why all physicians should include care for the uninsured as a significant part of their practice.

Following David Letterman's example, I will give you my list in reverse order.

Reason number 10: You should provide health care to the uninsured because it might save your life. I say this because several years ago, late at night, I was in downtown Memphis on the banks of the Mississippi. Admittedly, I was somewhere I should not have been. I was not thinking. Out of the shadows stepped a man who I am certain, without a doubt, was 10 feet tall. He walked toward me, and as he did, my life flashed before my eyes. I reached for my wallet, hoping that he would not kill me. He came right up to me, looked in my eyes, and said, "Ain't you my doctor?" At which point, I replied, "Yes, Jesus, I am." Reason number 10: It might save your life.

Reason number 9: The person you care for might sing at your daughter's wedding. Robert worked as a church janitor, but he also sang tenor in a well-known Memphis gospel quartet. He came to me once with a hoarse voice. As it turned out, he had a large vocal polyp, which a head and neck surgeon removed without charge. For more than a year Robert's voice was better, but he still could not sing tenor. But his voice slowly improved, and about 1 year ago, at the wedding of the head and neck surgeon's daughter, Robert was again singing tenor with his gospel quartet. This time, he was the one who did not charge for his services. Reason number 9: The person you care for might sing at your daughter's wedding.

Reason number 8: The safety net has a huge hole. In every city in America, the city- or county-funded hospitals and clinics are suffering from inadequate funding. Graduate medical education money has been cut right and left. There is barely enough money and staff to take care of the sickest patients, so who will care for the people with diabetes and hypertension before they have their stroke or heart attack? You are fooling yourself if you can sit back and believe that the training hospitals will take care of the poor. If that day ever existed, it has since passed. Reason number 8: The safety net has a huge hole.

Reason number 7: Waiving your fee can be as healing as the surgery itself. William had an anterior myocardial infarction 10 months ago. He was in the hospital for a while but is now out and doing fairly well physically, but the first day I saw him he was a beaten man. The total of his medical bills was more than $80,000. How can you pay a bill like that when you make $7 an hour working as a carpet layer? The collection agency has taken his house and his life savings, and now his wife and 2 daughters are barely making it in a 2-bedroom apartment. William was not too worried about his future medical care that first day I saw him. Instead, he said to me the saddest words, "It would have been better if I had died." Medically, we saved him, but spiritually he is dying. Reason number 7: Waiving your fee can be as healing as the surgery itself.

Reason number 6: At least for now, medicine is a helping profession, not a business. I know some people will say that I am living in the past to claim this, but I hope not. Every physician I know went to medical school in order to help people, not to run a business. Managed care may have changed the health care industry, but I hope it has not changed the hearts of the people who are physicians. And as long as we are in a helping profession, then we must care for all those who need our skills, regardless of their ability to pay. Reason number 6: Medicine is a helping profession, not a business.

Reason number 5: If not you, then who? Reason number 5: If not you, then who?

Reason number 4: You never know what the person has done for you. When Phen Phan first came to the Church Health Center of Memphis, he came as an interpreter for a Vietnamese woman. Without paying much attention, I noticed that a cane was in the corner, and I mistakenly believed that it was the patient's. It was, instead, Phen Phan's. When I looked closer, I realized that Phen Phan needed the cane because he was a bilateral amputee.

A few weeks later, Phen Phan came to me himself as a patient, and I learned his story. During the Vietnam War, he was a lieutenant in the South Vietnamese army. He worked with American troops clearing mine fields for 5 years. In 1970, he stepped on a mine and it blew off both his legs. At the end of the war, he knew that the North Vietnamese would come looking for him because he had helped the Americans. He fled the country and headed to Thailand but had to cross Cambodia when it was ruled by the Khmer Rouge. He made it to the Thai border, where he met a group of other refugees. Together they built a boat and planned to sail into Thailand from the sea. They were stopped by pirates, however, who robbed them and turned them over to the Khmer Rouge. They were tied together on the boat and taken out to sea, and the boats were sunk. Somehow, Phen Phan got free and clung to a piece of driftwood for 3 days and eventually floated onto shore in Thailand.

He was taken to a refugee camp, where he spent 3 years. A young American physician taught him English, then helped him get a visa to his hometown of Memphis. Phen Phan has lived in Memphis ever since. He helps others whenever he can by serving as a translator, and he works full-time as a security guard. With no legs, I am not sure what kind of a security guard he is, but I suspect that he was totally dedicated to saving the lives of the American soldiers whom he helped protect by finding mines. Did he save the life of someone who is close to me? Reason number 4: You never know what the person has done for you.

Reason number 3: There but for the grace of God, go you or I. Merilyn was 41 years old when she had chest pain and went to the emergency department. She had a good job, with good insurance. She was married and had 2 small children. A 41-year-old woman is not supposed to have a heart attack, but that is what happened to Merilyn. She received excellent care, had bypass surgery, and did well for the first 12 hours. She then lost the pulse in her right leg. Twenty-four hours later, she lost the pulse in her left leg. Twenty-four hours after that, she had both legs amputated at the hip. In the course of her ordeal, she used up her lifetime health insurance benefits, not to mention that her life was changed forever.

She applied for TennCare, Tennessee's Medicaid managed care program, but since she had insurance, she did not qualify. It did not matter that she had used up her life benefits, she had insurance.

She eventually found her way to us, and I have been her physician for the last 3 years. She never dreamed that she would be in this situation. No one ever sees the train coming. Reason number 3: There but for the grace of God, go you or I.

Reason number 2 (which could easily be reason number 1): All physicians in America acquired their medical educations because poor people allowed them to learn on their bodies. That is an educational debt you can never repay. Long after you have written the last check to the university, the kind of physician you are is in large measure due to a series of gifts that unnamed poor people gave you. You will never be free of the obligation to care for their families and loved ones in an attempt to repay the debt you incurred by becoming who you are. Reason number 2: All physicians in America acquired their medical educations because poor people allowed them to learn on their bodies.

And reason number 1 (which explains why every physician should provide health care for the uninsured; I know it should be profound, but it is not): It is simply because it's the right thing to do. Willie was my patient for several years. He was tall and lanky and full of laughter. He told jokes all the time and got away with things with my nurses that nobody else could. I remember him most for his hands: they were huge and calloused. The last time I saw him he was doing well, but the next day, a woman called to tell me that he had died in his sleep. These things happen. As the woman thanked me for caring for him, I felt that something was not right about the situation. Willie was white, and I was sure this woman was black. I asked her how she knew him. She told me that several years ago she had found him on the street and had taken him home. "He was never much trouble—well, he was a little trouble when he was drinking, but all in all, he was no bother." She gave him a room to live in and fixed his meals. He worked out of the labor pool and would pay rent from time to time.

As she told me the story, she also told me the plans for the funeral. He was to be cared for at the Ford Funeral Home. Here, I stopped her. In Memphis, everyone knows that not many white folks use the Ford Funeral Home for their services. I asked her, "Who is paying for the funeral?" She replied, "Well, over the years, I've saved the money he gave me for rent, and I thought I'd use it to pay any expenses."

After hearing the story, I knew I had to go to Willie's funeral. When I got to the funeral home, I found him all laid out, wearing a suit. I was sure Willie had not had a suit on in 20 years, but he looked pretty good. After paying my respects, I went to sign the registry book. There was only one name in front of mine: Easter Taylor.

I went back to the clinic and told the nurses my story, at which point they stopped me. "You know," one of them said, "the woman you have been talking to is Easter Taylor, and she is also one of your patients."

I do not know about you, but I do not have it in me to be like Easter Taylor. If I see a Willie on the street, I am not going to bring him home and care for him. But I can take care of him when he is sick, and whenever Easter Taylor needs my skills, I can be there for her and whomever she brings to my door.

The number 1 reason every physician should provide health care to the uninsured: It is simply because it's the right thing to do.

Accepted for publication October 1, 1999.

Presented at the annual meeting of the American Head and Neck Society, Palm Desert, Calif, April 26, 1999.

Reprints: Scott Morris, MD, Church Health Center of Memphis, 1210 Peabody, Memphis, TN 38104.